23708 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES- USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Build Ing Address:6100 23708
_ 6�0 2D
Franc: --XITLICATION SUBMITTAL DA FE
CITY OF CUPERTINO-BUILDING DIVISION
Contra N LIc:Nce APPLICATION I PERMIT
BUILDINGELECTRICAL�PWM'BING IiAMCA TECORV CO
.rehitect/Engineer. Lk.Ne; /
QTY ELECTRIC P IT EE BUILD] ERMIT INFO
Address:
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION PERMITISSUANCE
Thereby afflrmthat l amlicensed under provlsionsof Chapter9(commmo- PLIANC L JOB DESCRIPTION
inense 1.1.f°n7000)onDlvfect. (the8uslnessandPro(aslonsC„ode,and my PooRs
license is ec full form and effect.
License Class LIcF
Date Contractor
ARCHITECTS DECLARATION "1000 AMPS
q�q�uu mO xpC l understand my plans shallbe teed es public records. OVER 10DO AMPS SQ.Fr.FLOOR AREA s/SQ.FT.
dzeZa Licensed Professional SIGNS ELECTRICAL
<<�6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MI
7 F,irA� I hereby afBrmthat l am exempt Imm the Contractor's License Law for the
F t'' follow(ng reason.(Eective 78115,Business ami Professions Cede:My ctty or
muntywhichmquimaper tWmrutruct,alter,U pmve,den lbh,ormpalr TT2AP.MEIPR LE]NST.
.<r anystructure prierto its Issuance,also requlreslhe applicant for such permltto
O V file a signed statement that he ls licensed pursuant to the provisions, the POWER CFS
�u•In Contnetor.License Law(Chapter 9(commenclng with Section 7000)of Divi- VALUATION 0� gon3ofthe Business and ProfemlomCode)or that he iii exempt therefrom and NC POOL ELECTRIC
X' the balls for the alleged exemption. Any Woa dui of Section not.5 by any
¢� beans for permit 'emptio livettmation penalty of not OUTLEISSWITCHTS.FIXTURES
pA fiP P R PP c P na Y°
five hundreddollarsof hepr. NEW RESIDENTIAL ELFLTR Ff.
�m ❑I,as owner of the property,or my employees with wages:theU a � S1OW£S TYPECONSTRIX:TION
compenutlon,wWdotM veer&and the structure lsnm lntendM eff for
O
to(Sec.7014,Business and Profealom Code:The Contractors LI a law
$� does not apply to an owner of property who Wilds or improves thereon,and OCC.GROUP RES.UNITS
work himself orthrough his own employees,provided that such
Improvements arenot Intended oroffered for sale.If,however,thebullding or TOTAL:
Improvement b sold within one)earofcompletloN theowner-W fiderwlll have
tIAk11menof proving that he did not build or improve for purpose of sale.). QTy. PLUMBING PERMIT FEE FLOOD ZONE APN
LJ L as owner of the property,am exclusively contracting with limned PERMIT ISSUANCE
rontracton to construct the project(Sec.7044,Business and Profession Code: rN r\1
The Contractor's License law don not apply to an owner of property who A .DRAIN&VENT=WA
Wilda ar Improves thereon,and who contracts for such p(ujecte with a
TER
g5actorO licensed pursuant to the Contractor's License Law. JAS
ACK FLOW PROTECT.IDEVICE 1 FEE SUMMARY
cI,-JI am exempt under See B k P C for this reason
Owner RAINS FLOOR ROOF,A SANITARY Y_ N_
Date RECEIPT N
WORKMAN COMPENSATION DECLARATION COOL TAX Y_ N_
QI hereby affirm that I have a certificate of consent to self-Insure,ora RECEIPT M
nrtl(Icate ofWorker'Comperuatlon insurance ma certified ropy thereof(Sec.. EA.SYSTEM-1 WC.40IflT.E15 PARK FEE Y N
3800,Lab C.)
Policy If RECEIPT M
Corn ny AS EA.SYSTEM-OVER4(FA) BUILDING DIVISION FEES
(TCedified ropy I hereby fumished.
Certified copy is filed with the city inspection division. REASE/INDUSLRL WASTE INTERCEPTOR PLANCHECK FEI�
GREASE TRkP v L CyJy✓R
CERTIFICATEMPE EXM SATION N FROM WORKERS' PAI
COMPENSATION INSURANCE SEWER-SANITARYSTORM EA 100171• CCeI t#
(1'hlssectlon need not be completed If thepermit Isfw one hundred dollars
(s1I mmifess.) WATER HEATER W/VENT/FLECTR ENERGYFEE Y
Ill--employ
anyhe Iscon.Inanfthework so as tobeco becomemit
Hissued,
I shall not employ any person In any manner ro u to become subject t°the WATER SYSTEM/TREATING PAID
n'Compenntbn laws of GllfomW.Data O WorkeZ Applicant NEW RESIDENTIAL PLMB. SQ.17T. Date Reoei t#
Z O NOTICETO esubjeAM:H,after making this Certificate of Exemption,you
I' H
should become subject to the Werken'Compenat ion provlalmu°f the Labor TOTAL:
W Code,you must forthwith comply with such provisions or this permitshall be
j deemed revoked. BUN
W C CONSTRUCTION LENDING AGENCY SEISMIC FEE
G FEE
1 I hereby affirm that there is a rontroctien lending agency for the perform- ELECTRIC FEE
0 anceofthe work forwhlchthLs permit Ls Issued(Sec.3097,Clv.C.) TOTAL. ELECTRIC EEE
(,) Lender.Names
ly I— Lender.Addiess QI'Y. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I mrt lfy that l have read this applicatinnand pate that theabovc informative
bor ect.l agresto comply with all city and county ordinances and gate lawn PERMIT ISSUANCE FEES PAID:
>- O' relating to building romtnction,and hereby authorize representatives ofthls
F Z city to enter upon the above-mentioned pmNrty for lnpecelon purposes. ALTERORADDTOMECH.
(We)agree to save,Indemnify an d keep harmless the City of Cu ped lou Date ReI:cipt#
V against liabilities,Judgments,cosi mica whlchmaymitrymyaceme AIR HANDLING UNIT IT010,0D0 CFM) SUBTOTAL:
agaWtsald Cl ctm
Inaegvenceoft gn ting olthlsrm
peit.
AIRHANDLING UNIT(OVER lo,"CFM) CONSTRUCTION TAX
Itum.f Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATE LS DISCLOSURE
Willthe applicant or future building oaupant store or handle hazardous HEATING UNIT(TO 100,000 BTU)
matedal as cleared by the Cupertino Municipal Code,Chapter 9.12,and the Date RCCCI t#
Health an i Safety Code Section 25532(a)2 HEATING UNIT(OVER 10g0W BTU) TOTAL:
C]Y. I]No
Will theapplicaut or future building occupant use equipment or devise VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit ham Mous air contaminants as defined by the Bay Area Air
Qua llty Management Di❑strict? BOILER-COMP(3HP OR 100,000 BTI) �P
4havereadthehamrclowmutedalsrequimwnmunderChapler6.95of BOILER-COMP BTU) " A I D
the Gllfornla Health&Safety Code,Section25505,25533and25534. i
understand that ifthe building dace not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT •��� s 'I
responsibility to notify theoccupant of the requirements which at be met g 1�
prior to Issuance of a Certificate of Omo pa mry.
cl ur fLIit uru
Owner or auth.rImd agent Date ISSUT:D BY'
TOTAL:
OFFICE COPY